The Hospital Trust
The Hospital Trust did not provide appropriate care when Mr S went to the ED on 16 October
22. Mrs N says the Hospital Trust did not provide appropriate care when Mr S went to the ED on 16 October. Mrs N says the Hospital Trust did not do a full examination or tell them the diagnosis, and it sent Mr S home the same day, although he was still very unwell.
23. In line with the GMC’s ‘Good medical practice’, all doctors should provide a good standard of practice and care. If they assess, diagnose or treat patients, they must: • adequately assess the patient’s conditions and examine the patient if necessary • quickly provide or arrange suitable advice, investigations or treatment if necessary and • refer a patient to another practitioner when this serves the patient’s needs.
24. The NHS’s ‘Hip pain in adults’ says causes of hip pain when walking could be osteoarthritis (a condition which causes joints to become painful and stiff), a joint infection or a hip fracture. The NICE Clinical Knowledge Summary ‘Osteoarthritis’ says tests such as X-rays and blood tests are not usually necessary but may be used to exclude other causes (such as a hip fracture or a joint infection), particularly when a patient’s condition has suddenly deteriorated, and recommends the following treatments: a. self-care management strategies for symptom relief b. pain relief and non-steroid anti-inflammatory drugs c. physiotherapy and occupational therapy d. surgery (where non-surgical treatments are ineffective).
25. When patients arrive at the ED, our ED adviser told us a triage nurse will do an initial assessment, and then a doctor will see the patient and do relevant assessments and investigations. The electronic records show the Hospital Trust did a blood test, urine test and X-ray on 16 October and suspected osteoarthritis. Our ED adviser told us the blood test and X-ray were appropriate and in line with the standards described above.
26. The Hospital Trust made two sets of observations and the results of these were normal. The Hospital Trust did a C-reactive protein blood test (high C-reactive protein shows a patient is likely to be unwell, but it does not say exactly why), and this was 6, which is normal. Our ED adviser told us the outcomes of these investigations did not suggest Mr S had a joint infection or sepsis on 16 October. Instead, the results suggested osteoarthritis, and the Trust recommended Mr S visit his GP. Our ED adviser told us this was appropriate, because the treatments for osteoarthritis described in the NICE guidance above are taken over a long time and primary care services (GP and community health services) would organise them.
27. We understand why Mrs N is concerned Mr S may have been developing sepsis, because the next day he had an infection. As Mr S’s C-reactive protein level was higher the next day, our ED adviser said he may have developed an infection in the meantime, but this was not evident on 16 October. Mr S was experiencing hip pain on 16 October, but it was justifiable doctors thought osteoarthritis was causing the pain at that stage, as this is an extremely common cause. The Infectious Diseases Society of America’s article ‘Diagnosis and Management of Prosthetic Joint Infection: Clinical Practice Guidelines’ 2013 explains septic arthritis and infections of artificial joints are rare, so it was reasonable doctors did not consider he had an infection, or prescribe antibiotics, on 16 October. We have not seen anything in the records to suggest Mr S had sepsis or that the Trust should have admitted him as an inpatient on 16 October.
28. Mrs N also says Mr S had severe thrush and doctors did not identify it. There is no record of oral thrush in the records, and no record that Mr S told the ED doctor about oral thrush. But our ED adviser told us staff in the ED would not routinely look for non-emergency conditions (such as thrush) unless a person complains of it. Mr S went to the ED complaining of hip pain, and it was appropriate that doctors focused on that. ED staff will concentrate on emergency symptoms, and so it would be unusual for them to assess oral thrush, which is normally something a GP assesses. NICE clinical guideline 138 says doctors should listen to and address any concerns the patient has. ED doctors do not need to assess non-emergency conditions the patient has not told them about.
29. Mrs N complains the Hospital Trust discharged Mr S inappropriately without pain medication. National guidance on management of pain from the College of Emergency Medicine guidance ‘Management of Pain in Adults’ says hospitals should assess a patient’s pain on arrival in the ED. The records say Mr S was in moderate pain in his triage assessment (a quick but meaningful face-to-face clinical assessment), but there is no evidence of a formal pain score recorded in the electronic records. It is not possible to say whether staff recorded pain scores in the handwritten notes, because we have not seen them. The observation charts include a note to record pain on movement, but staff left this blank. A clinical navigator (a senior staff member) assessed Mr S and said he was able to move well with a frame and so was happy to discharge him with a frame and pain relief. The electronic records say the Hospital Trust gave Mr S medication at 1.35pm, but there are no prescription charts or handwritten information available saying what medication it gave him or why (see later paragraphs about missing handwritten records). Our ED adviser told us the medication the Trust gave Mr S at 1.35 pm was likely for pain relief.
30. Based on the records saying Mr S was in ‘moderate pain’, the clinical navigator’s recommendation to discharge Mr S with medication for pain relief and the Hospital Trust’s record of giving medication, we think Mr S was in pain, and the Hospital Trust should have prescribed pain-relief medication when it discharged him. Based on what Mrs N has told us about Mr S being ‘left in pain’, and because the electronic records do not say the Trust prescribed Mr S with pain-relief medication when it discharged him, we think it most likely the Hospital Trust did not prescribe these. Our view is this was not in line with the GMC’s ‘Good medical practice’ requirement to provide suitable treatment.
31. Mrs N says the Hospital Trust did not tell them what the diagnosis was or give them a discharge letter. The GMC’s ‘Good medical practice’ guidelines say hospitals should ‘give patients the information they want or need to know in a way they can understand’. The electronic records say the Hospital Trust gave discharge information to Mr S verbally. Our ED adviser told us EDs do not usually give written discharge information to patients; it would be usual for ED staff to give this information verbally. Provided a patient can understand, staff would not be expected to tell this information to family. There is nothing in the records to suggest Mr S could not understand, but Mrs N told us her father was in so much pain that he was not able to understand the information. Unfortunately, without the handwritten records, there is no way we can tell if the level of pain Mr S was experiencing meant doctors should have considered given discharge information to Mr S in a different way, in line with the GMC’s ‘Good medical practice’ guidelines. Because of how much time has passed since this event, we do not think it would be useful to ask staff to give their account of it. We are unable to decide on this issue.
32. Mrs N says the Hospital Trust should have sent the GP a discharge summary. In November 2017, the NHS England Standard Contract was for Hospital Trusts to send discharge summaries to GPs within 24 hours. We have seen a Trust copy of a discharge summary asking the GP surgery to ‘follow-up’. The GP surgery told us it does not have a copy of this. The Hospital Trust sent us an electronic audit trail, which it says shows it sent the discharge summary electronically on 16 October 2018. Based on this evidence, we think it likely that the Hospital Trust sent it, but we cannot say why the GP surgery never received it. For this reason, we are not upholding a service failing for this issue.
33. Our decision is to partly uphold this complaint. While we think the Hospital Trust did appropriate assessments, there is no evidence it prescribed Mr S pain relief as it should have when it discharged him. It is likely this failing contributed to Mr S being left in pain, until he was admitted to hospital the following day. We think the experience of witnessing this experience, and knowing Mr S was in pain, was distressing for Mrs N and her family.
The Hospital Trust lost Mr S’s notes when he returned to the ED on 17 October
34. Mrs N told us her father’s notes (from 16 October 2018) went missing on 17 October after a staff member visited Mr S to take blood tests. She said she asked a nurse to make a report on the Hospital Trust’s Datix system (a system to collect and manage data on bad events), but she does not know if the notes were ever found.
35. A staff member wrote in the medical records on 18 October that they had been ‘contacted by A&E we have lost notes. Plan to find notes’. The Hospital Trust admitted it could not find the records relating to Mr S’s admission on 16 October when he returned to the ED on 17 October, but it said staff found these records later and filed them with Mr S’s medical notes. The Hospital Trust said it could not say how long the notes were missing for, as there was no documentation of when staff found them.
36. NHS Trusts should store and process patients records in line with the GDPR in the Data Protection Act 2018. The GDPR say organisations must process personal data securely, and this includes protection from accidental loss. The GDPR say accidental loss of personal data is a personal data breach.
37. The GDPR say organisations must notify the Information Commissioner’s Office of a personal data breach within 72 hours unless the breach is unlikely to result in a risk to the rights and freedoms of individuals. In line with the GDPR, organisations should do a risk assessment to determine if the loss of information is a risk. If organisations think it unlikely there is a risk, they do not need to notify the Information Commissioner’s Office, but they should keep a record of the personal data breach and the risk assessment.
38. The Hospital Trust has not provided us with the handwritten notes from 16 October. It told us it has no other records (apart from the electronic records) relating to the ED attendance on 16 October 2018. For this reason, we think the Hospital Trust lost the handwritten notes and did not store Mr S’s records securely as it should have, in line with the GDPR requirement to process personal data securely.
39. The records we have seen suggest the Hospital Trust did not find the missing records or add them to the medical records, as it said it did. We criticise the Trust for telling Mrs N that staff found the notes and filed them with Mr S’s medical notes when the evidence suggests the notes are still missing. We consider the Trust did not act in line with our ‘Principles of Good Complaint Handling’, which say organisations should be open, honest and accountable, because it did not tell Mrs N that the notes were still missing but told her, incorrectly, that staff had found them.
40. The Hospital Trust said it did not report the lost notes on its incident reporting system (as a breach of confidentiality), and we have not seen that it did a risk assessment. We consider this to be a failing, as it is not in line with the GDPR requirements to keep a record of the data breach, do a risk assessment and consider if the loss of information is a risk that would require it to report the breach to the Information Commissioner’s Office. Without seeing a risk assessment, we cannot say whether the Hospital Trust should have reported the loss of records to the Information Commissioner’s Office.
41. Mrs N says the lost records caused a delay in identifying Mr S’s problems and in providing treatment on 17 October. Our ED adviser told us the missing records would not have affected the treatment Mr S received on 17 October, because the electronic records from 16 October did not suggest Mr S had a hip infection or needed antibiotic treatment. The Community Trust diagnosed the infection using blood tests in mid-November, and the missing handwritten records would not have provided any information to help doctors make a diagnosis any earlier. As the Hospital Trust did not complete a risk assessment, there is not enough information for us to say what the impact was on Mr S.
42. While we do not think the lost notes affected Mr S’s diagnosis or treatment, we recognise and understand Mrs N believed the lost notes contributed to delays in diagnosis of his infection, which was distressing. Mrs N told us finding out the Hospital Trust never found her father’s lost notes, when it told her it had, caused her even more stress and upset because she considers the Hospital Trust lied to her. She told us she is accessing counselling support for this distress. We recognise this information was distressing for Mrs N, but we hope our report reassures her the lost notes did not have the impact she believed it did on her father’s care. The Hospital Trust apologised that staff could not find the notes, but we do not think an apology is enough to minimise the chances of the failure happening again, and our decision is to uphold this complaint.
The Hospital Trust did not treat Mr S’s sepsis appropriately during his admission
43. When Mr S returned to the ED on 17 October, the repeat blood results showed signs of infection. The doctor discussed Mr S’s case with a senior ED doctor and documented a possible joint infection in the replacement hip (this is known as septic arthritis, which, according to our ED adviser, is a general term describing how an infection is affecting the joint, but it does not necessarily mean the patient has sepsis). The records say the senior ED doctor advised doctors to withhold antibiotic treatment until the orthopaedic doctor saw Mr S.
44. Mrs N says the sepsis team did not review Mr S. The Hospital Trust said all medical and nursing staff are trained to recognise and treat signs of sepsis, so suspected sepsis does not need to be referred to the sepsis team. NICE clinical guideline 51, ‘Sepsis: Recognition, diagnosis and early management’ says, for patients with one or more high-risk criteria for suspected sepsis, hospitals should:
• arrange immediate review by a senior clinical decision maker (an emergency care ST4 or above or equivalent) • do venous blood tests (testing blood from a vein) • give intravenous antibiotics (through a needle or tune inserted into a vein) within one hour and • discuss with a consultant.
45. The records show the ED team considered sepsis and did a sepsis screening, but Mr S’s NEWS did not raise any concerns. NEWS is a tool used to identify patients who are acutely unwell. It is relevant for patients with suspected sepsis because the NEWS score measures respiratory rate, oxygen saturations, blood pressure and temperature, which are indicators for sepsis. The documentation shows the Trust took three sets of observations at 6.47pm, 10.35pm and 2.40am, with NEWS scores of 1, 1 and 0 respectively, and Mr S’s temperature was normal at these times. This meant Mr S was considered at low risk of sepsis, based on his clinical assessment and observations on 17 October.
46. Our ED adviser told us there was no evidence of sepsis on 17 October. For this reason, we cannot say the Hospital Trust went against NICE clinical guideline 51, ‘Sepsis: Recognition, diagnosis and early management’ by not giving him antibiotic treatment at the time.
47. The British Medical Journal’s guidance on the treatment of septic arthritis, ‘Management of septic arthritis: a systematic review’, is to diagnose the cause of the infection and prescribe appropriate antibiotics. The Infectious Diseases Society of America’s ‘Diagnosis and Management of Prosthetic Joint Infection: Clinical Practice Guidelines’ say doctors can hold off giving antibiotics until they have done diagnostic testing: ‘a diagnostic arthrocentesis [a procedure to remove fluid around the joints] should be performed in all patients with suspected acute prosthetic joint infection unless the diagnosis is evident clinically and surgery is planned and antimicrobials [antibiotics are a type of antimicrobial] can be safely withheld prior to surgery’.
48. The orthopaedic doctor saw Mr S at 6am on 18 October and wrote ‘hold off antibiotics unless unwell’. The Hospital Trust gave evidence to the coroner saying doctors decided to hold off antibiotics (unless Mr S had a raised NEWS score) until it had aspirated the joint (removed fluid for testing) to find the cause of the infection on 18 October. The Hospital Trust said giving antibiotics before an aspiration procedure would reduce the chance of getting results. On 18 October, blood tests showed a staph aureus (bacterial) infection, and at 12.30am, microbiologists advised doctors to give Mr S antibiotics, and the prescription chart shows these were given at midday. At 4.15pm, blood tests confirmed Mr S had sepsis.
49. Our orthopaedic adviser told us the doctor’s decision to hold off prescribing antibiotics while waiting for the results of tests was in line with the Infectious Diseases Society of America’s ‘Diagnosis and Management of Prosthetic Joint Infection: Clinical Practice Guidelines’. He told us, if a patient takes antibiotics before testing, the samples are unlikely to grow microorganisms. He told us a decision about antibiotics would depend on how unwell a patient is. If a patient is acutely unwell (for example, if they have established sepsis) there will not be time to take samples before giving antibiotics. While Mr S was showing signs of sepsis early on 18 October, he was not acutely unwell, so it was appropriate to start the antibiotics after the testing. Our orthopaedic adviser told us the Hospital Trust gave appropriate treatment for an infected prosthetic joint.
50. The Hospital Trust Root Cause Analysis (RCA) (a process to find the main cause of something happening) identified a delay in medical staff responding to Mr S’s high NEWS score (of 5) on 18 October at 7.07pm. In line with Royal College of Physicians ‘National early warning score (NEWS)’ guidance, nurses should have reported this to a doctor immediately. There is no evidence in the medical records this happened. A doctor reviewed Mr S at 8.40pm (93 minutes later). Our orthopaedic adviser told us this did not affect Mr S because treatment for sepsis is antibiotics, and Mr S had started antibiotic treatment earlier that day (at midday), and when the doctor saw him 93 minutes later, his scores were stable.
51. The Hospital Trust continued to give Mr S antibiotics until it started providing end-of-life care on 5 November.
52. Our decision is the Trust started antibiotic treatment for Mr S’s sepsis in line with the British Medical Journal’s guidance ‘Management of septic arthritis: a systematic review’. We understand this decision may be disappointing for Mrs N, particularly as Mr S did go on to develop sepsis, but we cannot say the Hospital Trust went against guidelines by not giving him antibiotics earlier. While medical staff did not review Mr S as early as they should have done (when he had a high NEWS score on the evening of 18 October), we do not think this delay had an impact because the Trust was already providing the correct treatment in line with NICE clinical guideline 51, ‘Sepsis: Recognition, diagnosis and early management’. Our decision is to not uphold this complaint.
The Hospital Trust did not provide Mr S with appropriate nutrition or help him to eat, and it should have considered nasogastric tube feeding before 31 October
53. Mrs N says staff gave Mr S food and left him to eat it himself, but he did not have the strength to feed himself. She said his oral thrush made eating uncomfortable and his family felt pressured to get to the ward at mealtimes so they could make sure he ate and had water to drink. She says the Hospital Trust should have started nasogastric tube feeding earlier and that staff only considered this after she suggested it.
54. First, we will consider how the Trust helped Mr S to drink. NICE clinical guideline 174, ‘Intravenous fluid therapy in adults in hospital’, says patients who are older or frail should receive 20 to 25ml of fluids per kilogram of body weight each day. The medical records show nurses encouraged Mr S to drink regularly as part of regular nursing checks, and the fluid balance charts, which record oral (through the mouth) and intravenous consumption of fluids, show the Hospital Trust gave Mr S enough fluids. The records say Mr S weighed 63kg on 23 October, and the Hospital Trust gave him between 1,500 and 1,900ml of fluid each day, which was an appropriate amount for his body weight, and shows he was well hydrated.
55. Now, we will consider nutrition. NICE clinical guideline 32, ‘Nutrition support for adults’, says:
• ‘healthcare professionals should ensure care provides food and fluid of adequate quantity and quality • all hospital inpatients should be screened for malnutrition on admission. Screening should be repeated weekly for inpatients • nutrition support should be considered in people at risk of malnutrition, defined as those who have eaten little or nothing for more than five days and/or are likely to eat little or nothing for five days or longer • healthcare professionals should consider enteral tube feeding [where liquid food is passed directly to the stomach or intestine through a tube] in people who are malnourished or at risk of malnutrition and • nutrition support should be cautiously introduced in seriously ill people requiring enteral […] tube feeding. It should be started at no more than 50% of the estimated target energy and protein needs (which is calculated at 25 to 35 calories per [kilogram] of body weight, per day)’
56. Our nurse adviser told us, in line with NICE clinical guideline 32, ‘Nutrition support for adults’, screening assessments should record how much support a patient needs with eating, and nurses should monitor nutrition, record any change in oral consumption and encourage oral consumption.
57. After Mr S had surgery on 23 October, the intensive care records say Mr S’s ‘nutrition [was] poor’ and he needed ‘lots of encouragement’ by 26 October. When staff moved Mr S to another ward on 26 October, nurses completed a screening assessment and wrote he had loss of appetite and was not able to feed himself. Nurses also wrote Mr S ‘tends to decline until explain the importance’ and they were encouraging oral consumption. The daily nursing records show nurses were supporting Mr S to eat throughout the day but say he would eat only small amounts. Intensive care doctors wrote a plan to give Mr S a high-calorie protein drink called Ensure, ‘because his oral food and fluid intake has decreased’. The Hospital Trust’s RCA report says: ‘in this time period [between 26 October and when the Trust fitted the nasogastric tube] there was also supplemented high protein drinks (Ensures) prescribed’. But we have not seen evidence in the medical records, or on the prescription charts, of the Hospital Trust giving Ensure before 30 October. We consider the medical records and prescription charts to be more persuasive evidence than the RCA report because the staff caring for Mr S at the time wrote those documents. We think it is likely that staff did not give Mr S Ensure, which is was not in line with NICE guidance to provide food of adequate quantity and quality.
58. Nurses encouraged Mr S’s family to come during mealtimes to encourage eating and drinking. Our nurse adviser told us this is good practice, because patients are often more likely to accept food from people they know. The research from Cardiff University, ‘Mealtime assistance for older adults in hospital settings and rehabilitation units from the perspective of patients, families and healthcare professionals: a mixed methods systematic review’, found using a mix of healthcare assistants, volunteers and family to support with mealtimes has a positive outcome. We understand Mrs N’s family felt pressurised to go to the ward at mealtimes, because they felt staff may not support Mr S to eat otherwise. If family members are unable to come in, our nurse adviser told us hospitals should make alternative care plans, such as arranging for a volunteer or healthcare assistant to help at mealtimes. The Hospital Trust said ward staff support patients with meals if they do not have friends or relatives to help them. The records suggest hospital staff were encouraging Mr S to eat and drink, and we cannot say they went against guidelines by asking his family for support with meals. But we understand Mrs N and her family may not have been aware ward staff would have supported Mr S if they were not there. The Hospital Trust apologised Mr S’s family felt pressured to get to the hospital at mealtimes.
59. Staff referred Mr S to the dietician on Saturday 27 October, when they identified he was not eating and drinking much orally. As part of the dietician’s role, they may recommend a nasogastric feeding plan. The Hospital Trust inserted a nasogastric tube on 30 October and prescribed nutritional supplements via the nasogastric tube (these started on 31 October). These supplements gave Mr S adequate calories, and this decision was in line with NICE clinical guideline 32, 'Nutrition support for adults’. It is not clear from the records who made the decision to insert the nasogastric tube, or who prescribed the supplements, but the records show the dietician saw Mr S and reviewed the feeding plan on 31 October. This happened two working days after the referral (dieticians do not work weekends). We have not seen the referral document in the records, and we cannot see what level of urgency was associated with the request, but NICE clinical guideline 32, 'Nutrition support for adults’, says nutrition support should be considered when people have eaten little or nothing for more than five days, and the Trust fit the nasogastric tube in line with this timeframe. The RCA said it has improved the referral process to dietetics (the staff dealing with how nutrition affects health), and ward staff now make referrals by email, allowing them to provide more detail and for dieticians to prioritise patients with the highest risk.
60. Mr S took the food well until the palliative care team removed the nasogastric tube on 6 November. Our nurse adviser told us patients nearing the end of their life do not usually have nasogastric feeding as it is considered invasive (involving the introduction of instruments or other objects into the body), and the focus is on comfort and dignity. The aim of nasogastric feeding is to provide nutrition to help the patient recover, and this is not appropriate for patients receiving end-of-life care. The records show nurses offered Mr S thickened fluids and yoghurt on 6 and 7 November but not on 8 November as he was sleeping. The records show nurses did not offer Mr S oral fluids on 10 November but there is no code to explain why. The Hospital Trust RCA recognised it did not record as it should have whether oral consumption was suitable for Mr S (based on patient’s requests and level of consciousness) or his level of consciousness. Our nurse adviser told us it is not unusual for patients (with reduced levels of consciousness) to not eat or drink, as it can be dangerous. Generally, Hospital Trust nurses completed the fluid records, and we do not consider their failure to record a code explaining why they did not offer fluids on 10 November to be significant enough to be a failing.
61. We think the Hospital Trust did not give Mr S protein supplement drinks, as doctors in the critical care unit recommended on 26 October, until the evening of 30 October. We consider this was not in line with NICE guidance to provide food of adequate quantity and quality. Mrs N believes the lack of nutrition affected Mr S’s overall condition and his chances of surviving his illness. She believes the lack of nutrition meant he lost weight, he was weaker and less able to fight the infection.
62. Agarwal and colleagues’ report ‘Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: results from the Nutrition Care Day Survey 2010’ found malnutrition and poor food consumption are associated with prolonged hospital stay, frequent readmissions and greater in-hospital mortality. But, while nutrition is very important to patient outcomes, our nurse adviser told us an improvement of Mr S’s diet (Ensure supplements between 26 and 30 October) would not have been enough to prevent his health from getting worse. Our orthopaedic adviser told us nutrition is important for long-term health and, although Mr S had poor nutrition over several days, improving his diet would not have had any immediate impact. While good nutrition can help people fight infections in the long term, our orthopaedic adviser told us because Mr S had acute sepsis, poor nutrition would not have affected his ability to recover, as he needed antibiotics treatment.
63. There is not enough information for us to say whether the Trust should have acted on the dietician’s referral or fitted the nasogastric tube earlier. Our view is the Hospital Trust did not give Mr S nutritional supplements drinks as soon as it should have. While we do not think this affected Mr S’s health, we consider the Trust should take appropriate steps to prevent this happening again, and our decision is to uphold this complaint.
The Hospital Trust did not diagnose or treat Mr S’s oral thrush
64. Mrs N said Mr S had severe thrush in his mouth and down his throat, but the Hospital Trust did not diagnose it. She said the family noticed it straightaway, but the doctors and nurses did not.
65. There are no references to oral thrush in the medical records. A dietician reviewed Mr S on 31 October, and a speech and language therapist (SALT) assessed him on 2 November. A SALT assessment includes a comprehensive swallow assessment and examination of mouth and throat. Neither the dietician nor SALT referred to oral thrush in their assessments, which they would have had they found signs of thrush. The SALT wrote ‘poor oral condition noted on assessment with dried secretions and blood’ and recommended regular mouth care. NHS information about ‘Changes in the last hours and days’ says when a person is dying, mucus (which the person is usually able to remove by coughing and moving around) can build up in their mouth and cause secretions. Our nurse adviser told us a build-up of secretions in the mouth is not a sign of oral thrush. Signs of oral thrush are white blisters, and a white coating on the tongue. The records show nurses gave Mr S mouthcare several times a day from 1 November, but the nurses did not document any evidence of thrush.
66. Despite there being no record of Mr S having thrush symptoms, on 28 October the Hospital Trust prescribed nystatin, which is treatment for oral thrush. Because Mr S was at high risk of developing thrush because he was on antibiotics and had poor nutrition, our nurse adviser told us the Hospital Trust could have prescribed nystatin to prevent it developing. The SALT also noted he had poor oral condition, and he was diabetic. These are all factors which can cause thrush. NHS information in ‘Nystatin’ says it can be used to prevent and stop people getting a thrush infection.
67. While we understand Mrs N’s concerns about Mr S having oral thrush, the records do not suggest Mr S had oral thrush, and say nurses gave regular mouthcare. For these reasons, our decision is to not uphold this complaint.
The Hospital Trust did not clean Mr S’s room adequately
68. The NHS England and NHS Improvement’s ‘National Standards of healthcare cleanliness’ 2007 require Hospital Trusts to complete audits, but they do not need to keep cleaning records.
69. The Hospital Trust shared its cleaning policy with us. This says it reviews cleaning schedules quarterly, and does annual patient-led cleaning inspections and a programme of audits and quality checks. The policy describes how often staff should clean rooms, and cleaning routines are in line with recommendations in NHS England and NHS Improvement’s ‘National Standards of healthcare cleanliness’ 2007. For example, the policy says staff should clean floors and low surfaces twice a day in very high-risk areas (such as the intensive care ward), and once a day in high-risk areas (such as a general medical ward).
70. The Trust’s cleaning policy says staff should empty bins frequently so they do not overflow, and all staff have a responsibility to report any concerns about cleanliness or tidiness to appropriate staff. If nurses become aware of overflowing bins, this policy suggests they should report them to cleaning staff. The Hospital Trust’s RCA said staff should put any heavily soiled or contaminated material in a separate clinical waste bag and immediately remove it when they leave the room and dispose of them in the sluice (a room designed for the disposal of human waste and for disinfection of dirty items).
71. In Mrs N’s letter to the Hospital Trust dated February 2019, Mrs N complained none of the rooms her father was in were clean. When her father was moved to a separate room because he had MRSA, she said the clinical waste bin in it was overflowing. Mrs N said her mother stayed two nights in her father’s room and was there all day for three days but did not see staff clean the room. On the third day, her mother asked a cleaner to clean the floor. Unfortunately, we have not seen any notes in the records about her request. Mrs N also said there were lots of flies in the light fittings.
72. The Hospital Trust said a cleaner should visit the ward every day. It said staff should clean a side room (where a patient has MRSA) daily with disinfectant and empty the bins twice a day (or more if needed). The Hospital Trust told us it did not keep cleaning records, as they are not needed under the NHS England and NHS Improvement’s ‘National Standards of healthcare cleanliness’ 2007, and so could not review whether the room was cleaned. But the ward manager said a cleaner came to the ward every day.
73. The Hospital Trust told us it does a monthly cleaning audit for general wards, in line with the NHS England and NHS Improvement’s ‘National Standards of healthcare cleanliness’ 2007. The Hospital Trust told us this is a physical check. It showed us the last audit it did for the ward Mr S was on before his admission. The audit score was 88.3%, which was below the necessary standards (which should be 95% for a general ward). As a result of this score, the Hospital Trust told us staff would need to improve in any areas which failed, and the Hospital Trust would complete a second audit within an hour. We have seen the Hospital Trust completed a follow-up audit, which passed at 100%.
74. Because the audit does not provide specific information about whether staff cleaned the rooms daily, how frequently staff emptied bins, or how clean the rooms were that Mr S was in on the days he was there, and because there are no cleaning records, there is not enough evidence available to help us decide on these issues. We understand this will disappoint Mrs N.
75. Mrs N also complained the clinical waste bin was very close to Mr S’s bed. Mrs N showed us a diagram to show where the bin was. We have seen a statement from Mr H (who visited Mr S in hospital) saying the bin was next to Mr S’s bed. There is no national guidance saying where clinical waste bins should be placed, or what distance they should be from a patient’s bed in an isolation room. The Hospital Trust’s infection control policy does not say where the clinical waste bin should be kept, but in its complaint response the Hospital Trust told Mrs N the bin should be against the wall at the end of the bed, or room. Based on Mrs N and Mr H’s accounts, we accept the bin was close to Mr S’s bed and not against the wall at the end of the bed, or room, as it should have been, according to what the Hospital Trust says is usual. As there are no national guidelines about the placement of bins, we cannot say the Hospital Trust went against guidelines, or this amounted to a failing.
76. We understand this issue is important to Mrs N, and Mrs N’s viewpoint is the rooms were unclean and staff were not cleaning as they should have been. We recognise this issue has caused Mrs N distress. Unfortunately, there is not enough information for us to decide whether the Hospital Trust cleaned Mr S’s rooms as they should have. We recognise Mrs N has told us she is not satisfied with our response on this issue and she does not accept what the Trust has told us.
The Community Trust
District nurses failed to practise good hand hygiene
77. Mrs N told us the coroner’s inquest said the MRSA infection started in Mr S’s scalp wound. Because of this, she considers the district nurses’ poor hand hygiene may have contributed to his infection.
78. NICE clinical guideline 139, ‘Healthcare-associated infections: prevention and control in primary and community care’, says all healthcare staff should be trained in ‘hand decontamination’ (washing hands) and staff must wash their hands immediately before and after every direct contact with a patient, and after any other activity or contact with a patient's surroundings which could potentially result in hands becoming contaminated. This guidance is consistent with the Community Trust’s hand hygiene policy, which includes information about hand hygiene and visual hand-washing guides.
79. Mrs N told us Mrs S (Mr S’s wife) left a clean towel and soap out for the district nurses at each visit, but never saw the district nurses wash their hands. The Trust’s hand hygiene policy does not allow staff to use ‘communal fabric hand towels’, so in line with the policy, the district nurses should not have used the clean towel Mrs S left out. The hand hygiene policy includes ‘alcoholic hand rub’ and ‘liquid soap and water’ as appropriate hand hygiene techniques and says healthcare workers should have ‘portable products’. Based on this information, it is possible the district nurses used their own alcoholic hand rub. There is no information in the records to say whether district nurses washed their hands.
80. The Community Trust said its staff have annual Infection Prevention and Control training, which includes hand hygiene. The Community Trust showed us evidence its Infection Prevention and Control team completed quarterly audits of hand hygiene in 2018 and 2019. These did not highlight any issues or actions. The Community Trust also told us the Infection Prevention and Control team complete annual audits and spot checks.
81. While we recognise Mrs N’s concerns that staff did not wash their hands, there are credible reasons why the district nurses would not have used the clean towels Mrs N provided, and we have seen evidence the Community Trust takes appropriate steps to train its staff on hand hygiene and audits this training. Our decision is to not uphold this complaint.
District nurses did not provide appropriate care for Mr S’s head wound
82. Mrs N said her father’s head wound was not healing properly. She said her family saw it was severely infected with redness and soreness around his scalp, but the district nurses did not pick this up. Mrs N said district nurses should have taken photographs of the wound and sought advice but did not do this.
83. The earliest mention we have seen of an infection was when the oncologist reviewed Mr S on 4 May 2018 and wrote, ‘there was a hint of infection in the excision site’. The oncologist prescribed Mr S with a week’s course of antibiotics. Mrs N told us she is not sure if the infection at this time was the same infection he had later, but says it got progressively worse after this.
84. On 7 July 2018, district nurses completed Mr S’s initial assessment, and then they reviewed and redressed Mr S’s wound twice a week. On 24 September, the records say Mr S’s wound was sloughy (soft and watery) and was leaking fluid, and the district nurses put an Aquacel fibrous dressing (this absorbs excess liquid and promotes healing and is suitable for wet wounds) on it. Between 7 July and 24 September, the notes suggest there was little or no progress or improvement in the wound’s healing.
85. The Community Trust told us its policy is to take a photo of the wound when staff first assess the wound, and then to photograph the wound every four weeks to monitor it. The specialist infection team, Community and Hospital Trusts and Clinical Commissioning Group’s MRSA infection report found district nurses did not document the wound reassessment at four-weekly intervals as they should have done. Hertfordshire Community NHS Trust ‘Pressure Ulcer Prevention Assessment and Treatment Policy’ says:
• frequency of risk assessment and skin inspection in the community setting should be done at the initial assessment and thereafter on no less frequently than a monthly basis… Reassessment should be sooner if there is deterioration in the patients’ self-reported condition… or skin-integrity and • wherever possible, photographs should support documentation of pressure ulcer assessment.
86. We can see the policy says staff should do photographic reassessment at least monthly. The Community Trust acknowledged it did not take any photographs at the assessment, or at four-weekly intervals, which is below its expected standards.
87. The Community Trust said the records do not indicate the wound was infected; staff did not record any concerns in Mr S’s clinical record and recorded his wound was healing appropriately with no signs of infection. The Community Trust said it was entirely possible Mr S’s wound was slow to heal and may have been red, inflamed and painful, but this does not indicate the wound was infected. Without photographic evidence, it could not conclude whether staff should have responded differently. It apologised for the anxiety this has caused.
88. Rutter’s 2018 article, ‘Identifying and managing wound infection in the community’, lists the following clinical signs of an infected wound: • warm/hot to touch • red • inflamed • swollen • increase in liquid • strong odour • growing in size • painful • wound has stalled healing.
89. Our district nurse adviser told us there is nothing in the district nursing records to suggest the wound was infected when the district nurses first assessed Mr S on 7 July. A plastic surgeon checked Mr S’s head wound at an outpatient appointment on 18 September, but did not note an infection. According to the GMC’s ‘Good medical practice’, our physician adviser told us if the doctor assessed the wound as being infected, they should have recorded this and confirmed a treatment plan. Because they did not do this, we think the wound was not infected on 18 September. By 24 September, the district nursing notes say the wound had signs of exudate (fluid that leaks out of blood vessels into nearby tissues) and was sloughy. The wound could have been described as slow healing or non-healing, and this is a sign of a possible infection. But our district nurse adviser told us it is not possible to say if the wound was infected or not without digital images.
90. Our district nurse adviser told us if a wound is slow to heal, district nurses can get clinical advice from the local tissue viability service for support and expert knowledge. There are no guidelines explaining when district nursing teams should refer a patient to a tissue viability specialist team. Without photographic evidence of the wound, we cannot say whether district nurses should have made a referral to the tissue viability team, or what the tissue viability nursing team might have recommended.
91. Our district nurse adviser told us there is no national guidance on when swabs should be taken, or when antibiotics should be started. He said if the district nurses suspected an infection, they could have done one or a combination of two things: • they could start antibiotics straightaway, based on any clinical signs of an infection. Some district nurses can prescribe medication, or they can contact the GP to ask for a suitable prescription • they could take a swab of the wound and send it to the hospital lab. The lab report will identify the nature of any infection, and advise on the appropriate antibiotic or • they could combine these approaches and prescribe a common antibiotic while waiting for the results of the swab test to confirm if the patient needs to change antibiotics.
92. The district nurses took none of these actions, which suggests they did not suspect Mr S had an infection. Without photographic evidence of the wound, we cannot say whether they should have taken these actions.
93. The Community Trust accepted it did not take photographs of Mr S’s wound at assessment, or monthly, as it should have, in line with the Community Trust’s policy. Our view is this was a failing. Our district nurse adviser told us photographs would help to identify any signs of infection, monitor healing and might help staff suggest a change of dressing. Hayes’s 2003 article ‘Digital photography in wound care’ says a photograph shows a snapshot of the wound, so any staff member can monitor improvement or deterioration. Also, district nurses could have shared photographs with the tissue viability team to ask for specialist advice on managing the wound.
94. Mrs N says because the district nurses did not take any photographs or identify an infection, this led to delays in Mr S receiving treatment. We recognise Mrs N’s concerns that by not taking photographs of the wound, the Community Trust missed opportunities to identify the wound was infected and to treat an infection earlier. Mrs N is concerned an infection in the head wound may have led to Mr S developing MRSA in his hip.
95. We understand Mrs N’s concerns about this, because the coroner concluded Mr S died of a ‘community-acquired infection’ (an infection a patient gets outside of a hospital or which is diagnosed within 48 hours of admission without any previous healthcare meeting) after surgery and his head wound was one of several possible sites where MRSA could have entered his body. At the post mortem, the pathologist found crust from the scalp wound was GRAM-positive cocci. Our physician adviser told us the bacteria was possibly staphylococcus aureus, a common bacterium normally found on skin, but which can cause disease when introduced into normally sterile sites in the body and usually causes septic arthritis.
96. The following points explain why it is not possible for us to conclude Mr S’s wound was infected, or the Community Trust missed opportunities to identify or treat an infection, which would have prevented Mr S developing MRSA in his hip.
• There is no photographic evidence of Mr S’s head wound.
• The wound was unlikely to have been infected on 18 September because the plastic surgeon did not recognise an infection.
• On 17 October, when Mr S was in hospital, the orthopaedic doctor wrote ‘infected ulcer left side of scalp’. But when the plastic surgeon followed this up the next day (18 October), he wrote ‘exposed outer table clean, no cellulitis (redness), unlikely source of sepsis’ and he recommended an iodine dressing. Our physician adviser told us this suggests the plastic surgeon did not think S’s wound was infected, because it was clean and without redness, and he did not prescribe antibiotics.
• The post mortem did not find bacteria in the underlying tissue in the head wound, and this shows the wound was not infected at the time of the post mortem, although antibiotics could have altered the results.
• Our physician adviser told us it is very difficult to determine the cause/source of an MRSA infection because staphylococcus aureus can live on many areas of the skin. The coroner found the head wound was only one of several possible sites where MRSA could have entered his body.
Considering this evidence, we think it unlikely the wound was infected.
97. The Community Trust accepted the lack of photography was below standards. While we think the wound was unlikely to be infected, Mrs N believed the lack of photography contributed to Mr S’s infection not being treated and MRSA developing, and this caused Mrs N distress and worry for a long time. The Community Trust apologised for the anxiety this has caused and said it has made the district nursing team aware of the importance of photographing the wound and regularly doing this at reviews. We consider the actions the Community Trust has taken would likely prevent this failing from happening again, but the apology on its own is not an adequate remedy for Mrs N’s distress. For this reason, our decision is to partly uphold this complaint.